Commercially available melatonin may be isolated from the pineal glands of beef cattle or chemically synthesized buy vytorin 30mg visa. However cheap 30mg vytorin free shipping, there is no standard preparation buy generic vytorin 20mg on-line, making studies very difficult to compare. Department of Health and Human Services) determined in 2004 that: “Evidence suggests that melatonin is not effective in treating most primary sleep disorders with short-term use, although there is some evidence to suggest that melatonin is effective in treating delayed sleep phase syndrome with short-term use. Evidence suggests that melatonin is not effective in treating most secondary sleep disorders with short-term use. No evidence suggests that melatonin is effective in alleviating the sleep disturbance aspect of jet lag and shift-work disorder. Unlike most hypnotics, it does not disturb sleep architecture and does not lead to habituation. Double-blind randomized placebo-controlled trials show that melatonin 1 2 improves sleep, reduces sleep onset latency and restores sleep efficiency in patients 3 with insomnia. Like Mischoulon and Rosenbaum, Berkeley Wellness advises talking to a physician first and assuring that the dosage and timing of melatonin use are appropriate. Thus, they suggest that “melatonin may possibly improve cognitive function to some extent in long-term use, with its 6 strongest effects being preventative. But the single study cited by Brown, while showing Alzheimer’s symptom improvement with melatonin supplementation, showed no mental status improvement compared to the placebo group. Melatonin may have a role in long term 8 prevention of neuro-degeneration, particularly if it is started at the age of 40 or 45. Mayo emphasizes that it is unknown whether melatonin can help them stay asleep, or whether its effects would carry over in younger people. In addition, Mayo cautions that the studies have been flawed and that little is known of long-term effects of melatonin. These studies are small in scale but suggestive, and worth considering until further research is done. Of course, complementary use of melatonin with psychotropic drugs should always be discussed with the prescribing physician due to the usual polypharmacy concerns. However, given the mildness of the side effects of melatonin, such complementary use should be considered if the side effects of psychotropic medication develop or are feared. The Natural Standard concurs: “Preliminary reports suggest that melatonin may aid in reversing … tardive dyskinesia associated with [use of] haloperidol (Haldol). However, a number of clinical symptoms characteristic of these disorders, such as sleep alterations and anxiety, might benefit from timely melatonin treatment, given the strong “indirect signs of a close relationship between melatonin and sleep…. Collectively, the available data on the effects of melatonin on sleep suggest that a nocturnal surge in melatonin production may be an important factor in normal human sleep regulation, and that melatonin deficiency might contribute to an altered sleep pattern. This would require careful monitoring of melatonin levels, since psychotropic drugs that affect norepinephrine or serotonin levels might alter the pattern of melatonin production. Although no dangerous interaction is known, adjunctive use of melatonin with psychotropics should be coordinated with the prescribing physician. Caffeine may raise melatonin levels, but its stimulative effects may also alter wake-sleep rhythms. The Natural Standard urges monitoring by the physician prescribing the medication. Like benzodiazepines (such as diazepam (Valium) or triazolam (Halcion)), often described as sleeping pills, melatonin can produce a “hangover" and drowsiness the next day. Persons taking benzodiazepines should beware of the potential for an additive effect. Melatonin has been linked to a case of autoimmune hepatitis and with triggering Crohn’s disease symptoms. Therefore, Berkeley says, pregnant women and children should never take melatonin. Berkeley also lists high blood sugar, breast swelling in men, decreased sperm count, gastrointestinal irritation, sleepwalking, the morning hangover effect (drowsiness in the morning) and dizziness as potential side effects. In the absence of better science, consultation with the health care professional providing care for the seizure disorder is essential while using melatonin. Persons with severe depression or psychotic disorders should consult with the health care professional providing care for the underlying disorder before using melatonin. Increased breast size and decreased sperm count and motility have been reported in men. Doses above 50 mg per day may have long-term effects on testosterone or prolactin levels. Thus, patients on long-term daily melatonin should be monitored for possible adverse effects. The notion that uncontrolled use of melatonin is completely safe rests on little research and on the common public experience of lack of significant short- term toxic effects. Long-term clinical and experimental studies are needed to address this important question, since disruption of the "delicate mechanism" of the circadian system is, in and of itself, a significant potential side effect. Other potential effects of large doses of melatonin include lowering of body temperature, reflecting changes in either energy metabolism or temperature regulation, and unwanted modifications in human reproductive function. Finally, Mischoulon and Rosenbaum caution that it is important to avoid bright light exposure during melatonin treatment, since even regular room light can rapidly suppress melatonin production. In addition, exposure to bright light could produce an adverse effect, since melatonin has been reported to increase photoreceptor susceptibility. For jet lag, they recommend 5-10 mg of fast-release melatonin just prior to departure. This is best done by measuring melatonin levels in the blood, saliva, or urine in order and supplementing according to the precise amount of the deficiency found. Thus, before deciding on a therapeutic dose to deal with insomnia, people should consult with a physician to determine the precise amount of supplementation needed. Note that these recommended dosages follow Fugh-Berman’s recommendation and are less than those recommended by Brown et al and Weil. Such treatment will restore the deficit in melatonin that the traveler will experience due to the advance of bedtime at the destination. Following a westward flight, when the day is extended rather than shortened, it would be advisable not to take melatonin at the local bedtime, when the endogenous level of the hormone is already increased. In principle, this would facilitate resumption of sleep and its maintenance, plus delaying the circadian phase and adjusting to the new location. Sleep laboratory studies are essential to understanding melatonin’s effect on quality of sleep. But studies are split when it comes to proving a link between an individual’s consumption of omega-3s and lowered depression. All of the eight sources that discuss omega-3s acknowledge that there is promising evidence for omega-3s in the treatment of depression. Three studies do not recommend it, saying that the evidence is not conclusive enough. The evidence is slim, but these are additional reasons to consider a heart-healthy diet rich in omega-3s. Side effects and drug interactions are the same as eating fish, and appear minimal. Given the side effects and the likely benefits, the use of omega-3s in pregnancy and breastfeeding and in young children seems reasonable. Drug Interactions/Contaminants  Anticoagulants, like aspirin, warfarin, or heparin may interact to increase the risk of bleeding, though clinical evidence does not confirm this. Vegetarians, Vegans, and Plant Sources Vegetarian and vegan diets are almost always very low in omega-3s, since fish oil is the most efficient way to obtain omega-3s. A diet rich in small, non-predatory fish — typically about 2 meals a week — is good for almost everyone. Use of a diet rich in non-predatory fish or fish oil may prevent or moderate both depression or bipolar disorder and may be effective in stabilizing mood and enhancing the effectiveness of conventional anti-depressants. Although the evidence is preliminary, omega-3s may also serve as a neuroprotectant. Other uses being studied may encourage use of omega-3s pending development of evidence to the contrary. Moreover, fish (but not fried fish), which is rich in protein and low in saturated fat, can replace less-healthful foods such as red meat.

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In short discount vytorin 20 mg overnight delivery, the usual principles of confidentiality apply cheap vytorin 20 mg overnight delivery, and any doctor who breaches confidentiality must be prepared to justify his or her decision purchase vytorin 30mg online. Good notes assist in the care of the patient, especially when doctors work in teams or partnership and share the care of patients with colleagues. Good notes are invalu- able for forensic purposes, when the doctor faces a complaint, a claim for compensation, or an allegation of serious professional misconduct or poor performance. The medical protection and defense organizations have long explained that an absence of notes may render indefensible that which may otherwise have been defensible. The existence of good notes is often the key factor in preparing and mounting a successful defense to allegations against a doctor or the institution in which he or she works. Notes should record facts objectively and dispassionately; they must be devoid of pejorative comment, wit, invective, or defamatory comments. Patients and their advisers now have increasing rights of access to their records and rights to request corrections of inaccurate or inappropriate infor- mation. In English law, patients have enjoyed some rights of access to their medical records since the passage of the Administration of Justice Act of 1970. The relevant law is now contained in the Data Protection Act of 1998, which came into effect on March 1, 2000, and repealed previous statutory provisions relating to living individuals, governing access to health data, such as the Data Protection Act of 1984 and the Access to Health Records Act of 1990. Unfortunately, space considerations do not permit an explanation of the detailed statutory provi- sions; readers are respectfully referred to local legal provisions in their coun- try of practice. The Data Protection Act of 1998 implements the requirements of the European Union Data Protection Directive, designed to protect people’s pri- vacy by preventing unauthorized or inappropriate use of their personal details. The Act, which is wide ranging, extended data protection controls to manual and computerized records and provided for more stringent conditions on pro- cessing personal data. The law applies to medical records, regardless of whether they are part of a relevant filing system. As well as the primary legislation (the Act itself), secondary or subordinate legislation has been enacted, such as the Data Protection (Subject Access Modification) (Health) Order of 2000, which allows information to be withheld if it is likely to cause serious harm to the mental or physical health of any person. Guidance notes about the operation of the legislation are available from professional bodies, such as the medical protection and defense organizations. In the United Kingdom, compliance with the requirements of the data protec- tion legislation requires that the practitioner adhere to the following: • Is properly registered as a data controller. It is important to understand the nature of the request and what is required—a simple report of fact, a report on present condition and prognosis after a medi- Fundamental Principals 53 cal examination, an expert opinion, or a combination of these. Because a doc- tor possesses expertise does not necessarily make him or her an expert witness every time a report is requested. A report may be required for a variety of reasons, and its nature and content must be directed to the purpose for which it is sought. Is it a report of the history and findings on previous examination because there is now a crimi- nal prosecution or civil claim? Is it a request to examine the patient and to prepare a report on present condition and prognosis? Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim? The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report. If necessary, the appropriate consents should be obtained and issues of confidentiality addressed. A medicolegal re- port may affect an individual’s liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer.

Cross-linking of collagen fibres causes calcium deposit formation (Herbert 1991) purchase vytorin 20mg amex, reducing penetrability of arterial tunica to lipids (e buy 20 mg vytorin amex. Lipid accumulation forms plaque proven 30 mg vytorin, enabling platelet adhesion and aggregation within the arterial lumen (Todd 1997). Thrombi and emboli can cause ischaemia and major organ failure (cerebrovascular accidents, myocardial infarction, renal failure, pulmonary embolus). Myocardial collagen cross-linking limits ventricular filling, so reducing stroke volume. Most respiratory insufficiency in older people is caused by ageing of airway tissue, chemical damage (especially smoking and environmental pollutants) and muscle atrophy. Average pulmonary function is halved between 30 and 90 years of age (Hough 1996); decreased expiratory recoil reduces vital capacity and lung compliance. Pulmonary circulation also suffers atherosclerosis, increases pulmonary artery pressures. Older people are more frequently malnourished than younger people (Doyle 1990) due to factors such as poverty, poor mobility, maldentition, lack of facilities or constipation. Gastrointestinal tract atrophy makes villi shorter and broader, reducing bowel fluid absorption (Herbert 1991). The liver is a major source of body heat, and so reduced hepatic function contributes to impaired thermoregulation. Central nervous system degeneration progresses throughout life so that older patients are more likely to suffer: ■ organic brain disease (e. However, confusion may be caused by ■ absence of sensory aids (glasses, hearing aid) ■ hypoxia ■ toxic metabolites ■ alcohol (alcoholism is increasing among older people (Godard & Gask 1991)). Therefore, apparent ‘confusion’ should be holistically assessed, and care planned to meet individual needs. Reality orientation can provoke aggression (sensory imbalance); psychiatry has developed a range of alternative approaches, such as validation therapy (Feil 1993), that seeks to empower rather than control people, but most approaches rely on verbal responses, limiting their value for intubated, sedated patients. As skin ages, epidermis flattens, with loss of papillae (Herbert 1991) so that epidermal and dermal layers peel apart more easily, causing pressure sores from sheering (see Chapter 12). Capillary loss reduces oxygen, nutrients and hydration; skin becomes dryer, more brittle and prone to tearing with delayed healing. Most pressure sores occur in people over 70 years of age (Mihissin & Houghton 1995), hence the weighting for age on Waterlow and other assessment scales. Pressure area aids can reduce the incidence of pressure sores, but optimising endogenous factors (nutrition, perfusion) reduces risks. Muscular and skeletal atrophy contribute to weakness (which delays weaning from ventilation). Mortality is easily measured, but quality of life is a more valuable (if more subjective) measure of outcome. Conflicting research and practice makes healthcare for the critically ill older adults into a covert lottery. Ageism ‘Ageism’, the ‘notion that people cease to be people…by virtue of having lived a specific number of years’ (Comfort 1977:35), leads to ■ prejudice ■ stereotyping ■ negatives attitudes (Redfern 1991) and may be overt (e. Today’s elders grew up before the National Health Service existed, and so remember a very different society (and social values)—doctors (and nurses) then were presumed always to know best. Therefore, the beliefs and values of the older patients may differ significantly from those of the nurses caring for them—and different generational values may cause misunderstandings. Bereavement, social mobility and physical immobility are more likely to leave older people isolated, depriving them of the social supports (families, friends) that younger people usually have; friends and family may treat the older person as a burden. Psychological isolation can become self-fulfilling, encouraging older people to adopt child-like dependent behaviour and/or appear confused. Problems encountered by older people using hospital services can persist after leaving the department; specialised assessment forms for older people (e. De Beauvoir (1970) is highly readable, providing challenging sociological perspectives. Some useful, albeit largely quantitative, medical studies have been published in recent years, including Castillo-Lorente et al. The effect of physiological ageing on older patients in intensive care is discussed by Kilner and Janes (1997). Clinical scenario Frank Hobson is a very socially active and independent 84-year-old retired civil servant. Note the main age-related physiological changes and how these are incorporated into planning postoperative care. Immunocompromise and infection are often part of a complex pathological process; related material can be found in other chapters, especially chapters 9, 39 and 40. Exogenous infection is usually through contact (staff, procedures, equipment), but can also be airborne. Immunity develops with age and exposure to pathogens so that children are at greater risk of infection (e. Highly invasive equipment used with critically ill patients provides multiple entry sites for microorganisms so that benefits should be weighed against infection risks. Enteral tubes and infected feeds facilitate microorganisms entry into the gut, bypassing many nonspecific immune defences (e. Feeds standing for prolonged times at room temperature provide ideal media for bacterial growth. Forty-five per cent of patients stayed over 5 days, with infection rates tripling after 3– 4 days. Patients staying longer were usually sicker, but exposure to secondary infections compounded mortality. The report suggested that one-half of nosocomial infections were preventable, with risks increasing when units had more than eleven beds. Organisms Bacteria are small, usually 1–2 micrometres in diameter, and a single bacterium will divide up to a million times within 6 hours (Wilson 1997). Gram positive or gram negative levels indicate whether bacteria retain crystal violet-iodine complex stain (Murray et al. Gram negative organisms cause 70 per cent of all cases of sepsis (Wardle 1996), while mortality from gram negative septicaemia is 40–70 per cent (Michie & Marley 1992). There are over 170 strains of Staphylococci, mutations and variants making control problematic. Skin colonisation (throat, groin, axillae) by Staphylococci is widespread (Murray et al. Chlorhexidine reduces surface colonisation, while most strains remain susceptible to vancomycin (Murray et al. Most strains of Pseudomonas cannot survive human body temperatures, but Pseudomonas aeruginosa grows at body temperatures, tolerates 40–42°C (Murray et al. An opportunistic organism, skin colonisation occurs in only 2 per cent of healthy adults, but 38 per cent of hospitalised patients and 78 per cent of immunocompromised patients (Murray et al. Amphotericin is the most widely used anti-fungal drug, although some fungi have developed resistance to this (Richardson 1994). Controlling infection Infection-free environments remain unrealistic, but the spread of infection can be controlled. Endogenous infection requires ■ a source Infection control 131 ■ means of transmission ■ means of entry. Family and friends rarely move between patients, but staff can easily transfer hospital (often resistant) pathogens between patients. Hygiene (especially handwashing) temporarily reduces numbers of skin-surface bacteria; particularly problematic pathogens may be targeted by specific treatments for staff (e. The use of gloves and no-touch techniques significantly reduces cross-infection, but handwashing remains the simplest and most important way to reduce infection; minimising movement of staff between patients also reduces risks. Airborne bacteria can also be transmitted through ■ dust ■ airborne skin scales ■ droplets (e. Taylor’s (1978) classic study of nurses’ handwashing techniques identified poor technique by qualified staff; student nurses fared better, possibly due to recent education or anxieties about their clinical assessment. Poor handwashing technique may be improved through continuing (in-service) education (Gould & Chamberlain 1994) and feedback (Mayer et al. Intensive care nursing 132 Taylor also found that while palms of hands were effectively cleaned when handwashing, thumbs, tips of fingers and backs of hands were poorly washed. Fingertips, the most likely part to touch patients, may harbour bacteria unless consciously washed— observing almost anyone washing their hands (in or outside hospital) supports Taylor’s observation.

Death was delayed for up to 30 min after Taser use buy generic vytorin 30 mg on line, but it should be noted that the Tasers used in this study were using lower energy levels than those in current usage 20 mg vytorin with mastercard. Just as those suffering from extreme agitation need careful consideration when in custody order vytorin 30mg amex, individuals who have been agitated or unwell at the time of Medical Issues of Restraint 203 Taser use should have their acid–base balance checked. Taser use could exac- erbate an already disturbed acid–base balance by increasing skeletal muscle activity and predispose to the development of ventricular arrhythmias. Taser is being tested in a few United Kingdom police forces to be used by firearms-trained officers, and it seems likely to be issued nationally. In the United States, it has decreased in use since mace oleoresin capsicum sprays became widely issued because the latter appeared more effective. Tasers are available in parts of Australia to specialist officers and also subject to review of their effectiveness. More research on the medical effects of Taser usage will no doubt be forthcoming over time. Bean Bag Rounds Available widely in the United States and some Australian states but not the United Kingdom, bean bag rounds consist of rectangular, square, or circu- lar synthetic cloth bags filled with lead pellets and fired from a shotgun. For example, the “Flexible Baton” fires a bag containing 40 g of number 9 lead shot with a projectile velocity of approx 90 m/s. At impact, projectiles are designed to have separated from the shotgun shell and wadding, opened out to strike the target with its largest surface area before collapsing as they lose energy. The effect is to provide sufficient blunt force from an ideal range of 10–30 m to stop an adult’s progress. In one study (11), the most common injuries were bruising and abra- sions, followed by lacerations without having retention of the actual bean bag. However, significant other serious injuries have been documented, including closed fractures, penetrating wounds with retention of the bean bag projectile (and at times parts of the shell and/or wadding), and internal organ damage. Blunt injuries included splenic rupture, pneumothorax, compartment syndrome, tes- ticular rupture, subcapsular liver hematoma, and cardiac contusions. It was noted that retention of the bag was not always suspected on an initial clinical examination, being detected on subsequent scans. Clearly, this device has potential for significant trauma to anywhere on the body. Just as with other nonlethal alternatives for restraint, the forensic physician should always consider why such techniques needed to be deployed; use of drugs or alcohol and psychiatric illness are all common concurrent prob- lems in these situations. Cooper, Biomedical Sciences, Defence Sci- ence and Technology Laboratory, Porton, England, for information regarding baton rounds, and Sgt. John Gall and colleagues from Australia for providing information rel- evant to their jurisdiction. Discussion of “Effects of the Taser in fatalities involving police con- frontation. Detainees may have to be interviewed regarding their involvement in an offense and possibly further detained overnight for court; guidance may therefore have to be given to the custodians regarding their care. Although various laws govern the powers of the police in different juris- dictions (1), the basic principles remain the same (2,3). If an individual who is detained in police custody appears to be suffering from a mental or physical illness and needs medical attention or has sustained any injuries whether at arrest or before arrest, such attention should be sought as soon as possible. Increasingly, the police have to deal with individuals who misuse alcohol and drugs or are mentally disordered; if the detainee’s behavior raises concern, medical advice should be sought. Custody staff should also seek medical advice if an individual requests a doctor or requires medication or if the custody staff members suspect that the detainee is suffering from an infectious disease and need advice. In some areas, when a person under arrest is discharged from the hospital and taken to a police station, a doctor is called to review the detainee and assess whether he or she is fit to be detained and fit for interview (4). Medical assessments of detainees may be performed by either a doctor or a nurse retained to attend the police station (5,6) or by staff in the local hospital accident and emergency department (7). The basic principles on which doctors should base their conduct have already been outlined in Chapter 2. The health and welfare of detainees should be paramount, with any forensic considerations of secondary importance. The role of any physician in this field should be independent, professional, courteous, and nonjudgmental. If the police bring a detainee to the accident and emergency department or if the health professional is contacted by the police to attend the police station, it is important to find out why a medical assessment is required. It is essential that the doctor or nurse be properly briefed by the custody staff or investigating officer (Table 1). Fully informed consent from the detainee should be obtained after explaining the reason for the examination. Detainees should understand that they are under no obligation to give consent and that there is no right to abso- lute confidentiality. Notwithstanding the latter, custody staff should be given only that information necessary for them to care for detainees while they are in police detention. Such information will include details of any medical con- cerns, required observations, medication, and dietary requirements. Although those detained in police custody are usually young, there remains the potential for considerable morbidity and mortality among this group. There- fore, it is essential that a full medical assessment be performed and detailed con- temporaneous notes made. A sufficient quantity of medication should be prescribed to cover the time in detention. The medication should be given to the police in appropri- ately labeled individual containers or sachets; alternatively, medication may be prescribed and collected from the local pharmacist. It is most important that there is a safe regimen for medication administra- tion to detainees. Records should be kept showing that the prescribed medica- tion is given at the correct time and that any unused medicines are accounted for. Ideally, police personnel should ensure that when administering medication they are accompanied by another person as a witness, and the detainee should be observed taking the medication to prevent hoarding. If detainees are arrested with medications on their persons, medical advice should be sought regarding whether they should be allowed to self-administer them. It may be prudent for a physical assessment to be performed either in the custody suite or in the local hospital before self-administration of medications. Medication brought with the prisoner or collected from the home address should be checked to ensure that it has the correct name and dosage and that the quantity left is consistent with the date of issue. If there is doubt, police person- nel should verify with the pharmacist, family doctor, or hospital. If the medicine is unlabeled, it is preferable to issue a new prescription, especially with liquid preparations, such as methadone. The detainee should have access to food and fluids as appropriate and should also have a period of rest of 8 hours during each 24 hours. Epilepsy Many detainees state that they have “fits” and there is a need to differen- tiate, if possible, between epilepsy and seizures related to withdrawal from alcohol or benzodiazepines; it is also important to consider hypoglycemia. The type of seizure should be ascertained, together with the frequency and date of the most recent one. Treatment may be given if the detainee is in posses- sion of legitimate medication; however, if he or she is intoxicated with alcohol or other central nervous system-depressant drugs, treatment should generally be deferred until the detainee is no longer intoxicated. The custody staff should have basic first aid skills to enable them to deal with medical emergencies, such as what to do when someone has a fit. If a detainee with known epilepsy has a seizure while in custody, a medical assess- ment is advisable, although there is probably no need for hospitalization. How- ever, if a detainee with known epilepsy has more than one fit or a detainee has a “first-ever” fit while in custody, then transfer to a hospital is recommended. Diazepam intravenously or rectally is the treatment of choice for status epilepticus (11). Any detainee requiring parenteral medication to control fits should be observed for a period in the hospital. Asthma Asthma is a common condition; a careful history and objective recording of simple severity markers, such as pulse and respiratory rate, blood pressure, speech, chest auscultation, mental state, and peak expiratory flow rate, should identify patients who require hospitalization or urgent treatment (Table 4) (12). Detainees with asthma should be allowed to retain bronchodilators for the acute relief of bronchospasm (e. Diabetes It is often desirable to obtain a baseline blood glucose measurement when detainees with diabetes are initially assessed and for this to be repeated if necessary throughout the detention period. All doctors should have the means to test blood glucose, using either a strip for visual estimation or a quantitative meter. Oral hypoglycemics and insulin should be continued and consideration given to supervision of insulin injections.

R. Jesper. University of North Florida.

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